Application To Extend A Teaching Intern Certificate Form (Page 2 of 2) in pdf

PPLICATION TO

EXTEND

EACHING

NTERN

ERTIFICATE

– C

RIZONA

EPARTMENT OF

DUCATION

ERTIFICATION

NIT

3: C

ECTION

RIMINAL

ISTORY

- Answer EVERY question, sign and date. Attach Explanation of Incident, if required.

If “YES” is indicated for any of the following questions, you must attach an Explanation of

ATTENTION:

Incident form to your application before it can be processed. You may download the form at:

1.  YES__ NO___ Have you ever had any professional certificate or license,

2.  YES__ NO___ Have you ever received a reprimand or other disciplinary action

revoked or suspended?

involving any professional certification or license?

3.  YES__ NO___ Have you ever been convicted of any felony offense?

4.  YES__ NO___ Have you ever been arrested for any offense for which you

were fingerprinted?

5.  (Answer every

Have you ever been arrested for any of the following

(continued) Have you ever been arrested for any of the

question.)

offenses in this state or similar offenses in another

question.)

following offenses in this state or similar offenses in

jurisdiction?

another jurisdiction?

 YES__ NO___ Second-degree murder

 YES__ NO___ Continuous sexual abuse of a child

 YES__ NO___ Aggravated assault resulting in serious physical injury or

 YES__ NO___ Attempted first-degree murder

 YES__ NO___ Any other dangerous crime against children as defined in

involving the discharge, use or threatening exhibition of

a deadly weapon or dangerous instrument against a

section A.R.S. § 13-604.01

 YES__ NO___ Any of the above listed offenses if committed as a

minor under fifteen years of age

 YES__ NO___ Sexual assault

reparatory offense as described in A.R.S. 13-1001

 YES__ NO___ Molestation of a child

 YES__ NO___ Any offense causing you to register as a sex offender

 YES__ NO___ Sexual conduct with a minor

 YES__ NO___ First-degree murder

 YES__ NO___ Commercial sexual exploitation of a minor

 YES__ NO___ Armed Robbery

 YES__ NO___ Sexual exploitation of a minor

 YES__ NO___ Incest

 YES__ NO___ Child abuse

 YES__ NO___ Exploitation of minors involving drug offenses

 YES__ NO___ Kidnapping

 YES__ NO___ Sexual abuse of a vulnerable adult

 YES__ NO___ Sexual abuse of a minor

 YES__ NO___ Sexual exploitation of a vulnerable adult

 YES__ NO___ Taking a child for the purpose of prostitution as

 YES__ NO___ Commercial sexual exploitation of a vulnerable adult

 YES__ NO___ Abuse of a vulnerable adult

prescribed in section A.R.S. § 13-3206

 YES__ NO___ Child prostitution as prescribed in section ARS 13-3212

 YES__ NO___ Molestation of a vulnerable adult

 YES__ NO___ Involving or using minors in drug offenses

 YES__ NO___ Neglect of a vulnerable adult

I understand that pursuant to ARS § 15-534, any person who makes a false statement, representation or certification in any application for certification is

guilty of a misdemeanor offense. I swear or affirm that the foregoing information completed by me, or submitted by me for certification purposes is, to the best

of my knowledge, true and correct. Furthermore, should any part or all of the information herein provided prove to be false, I recognize that it shall be just

cause for revocation, suspension, or other disciplinary action against any certificate issued to me by the Arizona Department of Education.

____________________________________________ _____________

Applicant’s Signature

Date

** R

. **

EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE

RIZONA

EVISED

TATUTES AND

DMINISTRATIVE

ODE